Drugs Requiring Prior Authorization, Step Therapy and/or Quantity Limits
Some prescription drugs may require prior authorization, step therapy and/ or be subject to quantity limits. It is very important to make sure that prior approval is received before going to a pharmacy to fill your prescription. Please note: Some drugs may be subject to both prior authorization or step therapy and quantity limits.
If a medication may also be covered under the medical benefit and the drug will be given in the medical office, physicians should contact
Blue Cross and Blue Shield of NC for approval (These medications are marked with an asterisk *).
The State Health Plan may change the list of prescription drugs that require prior approval, step therapy and/or be subject to quantity limits.
If you disagree with a decision made during the prescription drug prior authorization process, you have the right to request that the State Health Plan or its representative review the decision through the grievance process. The grievance process is voluntary and may be requested by the member or an authorized representative acting on the member's behalf. Visit the PPO plan grievance page.
Provider Instructions
To initiate and/or complete prior authorizations (coverage reviews) with Medco, prescribers have several options available. First, prescribers with a Personal Identification Number (PIN) and password can log on to Medco's prescriber coverage review website (www.medco.com/coverage) to view existing coverage review cases for their patients, initiate a coverage review case for their patients (a rejected pharmacy claim must be on file in order to initiate a case), or complete a coverage review case (answer the coverage criteria questions required to determine coverage).
If a prescriber does not have, or does not know their PIN and password, please call Medco at 1-800-496-5661, 8:00am to 9:00pm, eastern time, Monday thru Friday, and a PIN and password will be provided.
Another option to initiate and/or complete a coverage review case is to contact Medco's coverage review department at 1-800-753-2851, twenty-four hours a day, seven days a week.